Gestational Trophoblastic Disease: Types of Treatment

Approved by the Cancer.Net Editorial Board, 03/2019

ON THIS PAGE: You will learn about the different types of treatments doctors use for women with GTD. Use the menu to see other pages.

This section explains the types of treatments that are the standard of care for GTD. “Standard of care” means the best treatments known. When making treatment plan decisions, you are encouraged to consider clinical trials as an option. A clinical trial is a research study that tests a new approach to treatment. Doctors want to learn whether the new treatment is safe, effective, and possibly better than the standard treatment. Clinical trials can test a new drug, a new combination of standard treatments, or new doses of standard drugs or other treatments. Clinical trials are an option to consider for treatment and care for all stages of a tumor. Your doctor can help you consider all your treatment options. Learn more about clinical trials in the About Clinical Trials and Latest Research sections of this guide.

Treatment overview

For GTD, different types of doctors often work together to create a patient’s overall treatment plan that combines different types of treatments. This is called a multidisciplinary team. For GTD, this often includes a gynecologic oncologist, a doctor who specializes in treating cancer of the female reproductive system. Other specialists may include a medical oncologist, surgeon, and radiation oncologist. Your care team may include a variety of other health care professionals, such as physician assistants, oncology nurses, social workers, pharmacists, counselors, dietitians, and others.

GTD is typically curable, especially when found early. The main treatments for GTD are surgery and/or chemotherapy. Descriptions of the common types of treatments used for GTD are listed below. Your care plan may include treatment for symptoms and side effects, an important part of medical care.

Women diagnosed with GTD may have concerns about whether treatment may affect their sexual function and ability to have children, called fertility, and these topics should be discussed with the health care team before treatment begins.

Treatment options and recommendations depend on several factors, including the type, stage, and risk grouping of GTD and the patient’s preferences and overall health. Take time to learn about all of your treatment options and be sure to ask questions about things that are unclear. Talk with your doctor about the goals of each treatment and what you can expect while receiving the treatment. These types of talks are called “shared decision making.” Shared decision making is when you and your doctors work together to choose treatments that fit the goals of your care. Shared decision making is particularly important for GTD because there are different treatment options. Learn more about making treatment decisions.

Surgery

Surgery is the removal of the tumor and some surrounding healthy tissue during an operation. It is often the first treatment used for a molar pregnancy and may be the only treatment necessary. A surgical oncologist is a doctor who specializes in removing a tumor using surgery.

For GTD, the extent of surgery depends on the stage of the tumor. Common surgical options include:

  • Suction dilation and curettage (D&C). During D&C, the doctor dilates the cervix and removes the tissues inside the uterus using a small vacuum-like device. After that, the walls of the uterus are scraped to remove any remaining molar tissue. The patient may receive a drug called oxytocin that helps the uterus contract to normal size. A D&C is used when there is a molar pregnancy and allows for preservation of a woman’s fertility. Side effects may include some vaginal bleeding, infection, scarring inside the uterus, cramping, and blood clots. Talk with your health care team about what to expect from this procedure.

  • Hysterectomy. A hysterectomy is the removal of the woman’s uterus and uterine cervix. In most cases of GTD, a hysterectomy is not necessary because women are cured with other treatments, including D&C and chemotherapy (see below). A hysterectomy is usually recommended to reduce the risk of recurrence or to treat a tumor type of PSTT or ETT. Types of hysterectomy include:

    • Simple hysterectomy: removal of the uterus and cervix

    • Supracervical hysterectomy: removal of the body of the uterus, while preserving the uterine cervix

    • There are different techniques used to perform a hysterectomy, including a traditional incision in the stomach or a technique that uses several, smaller incisions, called a laparoscopic hysterectomy. Side effects may include pain, bleeding, and infection. Talk with your health care team about possible side effects and how they can be relieved. Women who have a hysterectomy cannot become pregnant in the future.

Following surgery for GTD, the woman’s hCG level (see Diagnosis) will be monitored with blood tests to make sure that it returns to normal levels. If the hCG level remains high or increases after an initial drop, it may mean that tumor cells are still present, either in a portion of the original tumor—called a persistent or invasive mole—and/or the GTD has spread to another area. If this occurs, additional treatment such as chemotherapy will be recommended. If the GTD surgery shows the presence of choriocarcinoma, chemotherapy is started immediately. Choriocarcinoma is cancerous and always needs chemotherapy.

Before surgery, talk with your health care team about the possible side effects from the specific surgery you will have. Learn more about the basics of cancer surgery.

Chemotherapy

Systemic therapy is the use of medication to destroy cancer cells. This type of medication is given through the bloodstream to reach cancer cells throughout the body. Systemic therapies are generally prescribed by a medical oncologist, a doctor who specializes in treating cancer with medication. A gynecologic oncologist may also give chemotherapy to treat GTD.

The type of systemic therapy used for GTD is chemotherapy. Chemotherapy is the use of drugs to destroy tumor cells, usually by keeping the tumor cells from growing, dividing, and making more cells. Chemotherapy is usually very effective in treating a molar pregnancy and some types of GTN, but it is not as effective with PSTT and ETT. Sometimes, chemotherapy is used as a single treatment, and in other cases, it may be combined with surgery.

Systemic chemotherapy gets into the bloodstream to reach tumor cells throughout the body. Common ways to give chemotherapy include an intramuscular (IM) injection (or shot), an intravenous (IV) tube placed into a vein using a needle, or in a pill or capsule that is swallowed (orally).

A chemotherapy regimen, or schedule, usually consists of a specific number of cycles given over a set period of time. A patient may receive 1 drug at a time or a combination of different drugs given at the same time. Common drugs used in chemotherapy for GTD include:

  • Methotrexate (Rheumatrex, Trexall)

  • Dactinomycin (Cosmegen)

  • Etoposide (available as a generic drug)

  • Cyclophosphamide (available as a generic drug)

  • Vincristine (Vincasar)

  • Cisplatin (available as a generic drug)

Similar to surgery, the type of chemotherapy depends on the stage grouping of GTD, including whether the tumor is low risk or high risk. A low-risk invasive mole or a cancerous GTD that has spread can often be treated successfully with methotrexate alone or in combination with leucovorin (Fusilev). Another drug that can be used is dactinomycin, especially if the patient’s liver is not fully healthy. About 30% of women with low-risk disease will need additional treatment with a second drug.

Women with high-risk metastatic disease generally receive combination chemotherapy with more than 1 drug. Common combinations include:

  • EMA-CO: etoposide, methotrexate, dactinomycin, cyclophosphamide, and vincristine

  • EMA-EP: etoposide, methotrexate, dactinomycin, etoposide, and cisplatin

Treatment results are measured by testing the woman’s hCG levels. Usually chemotherapy is continued until hCG levels are normal. Additional cycles of chemotherapy are given after hCG levels are normal to reduce the risk of recurrence. In most instances, patients require 3 to 4 cycles of chemotherapy.

The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, mouth sores, hair loss, loss of appetite, neuropathy (numbness and tingling in the fingers and toes), and oto-toxicity, which is loss of high-frequency hearing and/or ringing in the ears. These side effects usually go away after treatment is finished. Talk with your doctor beforehand about the possible side effects from the specific drug(s) given and how side effects may be relieved or reduced.

Learn more about the basics of chemotherapy. The medications used to treat GTD are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. It is also important to let your doctor know if you are taking any other prescription or over-the-counter medications or supplements. Herbs, supplements, and other drugs can interact with medications to treat the tumor. Learn more about your prescriptions by using searchable drug databases.

Physical, emotional, and social effects

A tumor and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the tumor.

Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of GTD, may receive this type of care. And it often works best when it is started right after a diagnosis. People who receive palliative care along with treatment for the cancer often have less severe symptoms, better quality of life, and report they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the cancer, such as chemotherapy, surgery, or radiation therapy.

Before treatment begins, talk with your doctor about the goals of each treatment in the treatment plan. You should also talk about the possible side effects of the specific treatment plan and palliative care options.

During treatment, your health care team may ask you to answer questions about your symptoms and side effects and to describe each problem. Be sure to tell the health care team if you are experiencing a problem. This helps the health care team treat any symptoms and side effects as quickly as possible. It can also help prevent more serious problems in the future.

Learn more about the importance of tracking side effects in another part of this guide. Learn more about palliative care in a separate section of this website.

Remission and the chance of recurrence

A remission is when the tumor cannot be detected in the body and there are no symptoms. This may also be called having “no evidence of disease” or NED.

A remission may be temporary or permanent. This uncertainty causes many people to worry that the cancer will come back. While many remissions of GTD are permanent, it is important to talk with your doctor about the possibility of the tumor returning. The risk of recurrence for GTD overall is low, but it may be 10% to 15% for women with a high-risk tumor. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the tumor does return. Learn more about coping with the fear of recurrence.

If GTD returns after the original treatment, it is called recurrent. It may come back in the uterus (called a local recurrence), nearby (regional recurrence), or in another place (distant recurrence).

When this occurs, a new cycle of testing will begin to learn as much as possible about the recurrence. After this testing is done, you and your doctor will talk about the treatment options. Often the treatment plan will include the treatment described above, such as surgery or chemotherapy, but they may be used in a different combination or given at a different pace. Your doctor may suggest clinical trials that are studying new ways to treat this type of recurrent tumor. Treatment is often effective for a recurrent GTD. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects.

People with recurrent GTD often experience emotions such as disbelief or fear. You are encouraged to talk with the health care team about these feelings and ask about support services to help you cope. Learn more about dealing with cancer recurrence.

If treatment does not work

GTD is usually curable. However, recovery is not always possible. If a cancerous GTD cannot be cured or controlled, the disease may be called advanced or terminal.

This diagnosis is stressful, and for many people advanced cancer is difficult to discuss. However, it is important to have open and honest conversations with your health care team to express your feelings, preferences, and concerns. The health care team has special skills, experience, and knowledge to support patients and their families and is there to help. Making sure a person is physically comfortable, free from pain, and emotionally supported is extremely important.

People who have advanced disease and who are expected to live less than 6 months may want to consider hospice care. Hospice care is designed to provide the best possible quality of life for people who are near the end of life. You and your family are encouraged to talk with the health care team about hospice care options, which include hospice care at home, a special hospice center, or other health care locations. Nursing care and special equipment can make staying at home a workable option for many families. Learn more about advanced cancer care planning.

After the death of a loved one, many people need support to help them cope with the loss. Learn more about grief and loss.

The next section in this guide is About Clinical Trials. It offers more information about research studies that are focused on finding better ways to care for women with GTD. Use the menu to choose a different section to read in this guide.